Before we get into the specifics, I want to just talk about two general issues.  The first was we have kind of gone back and forth about whether this should be a separate, stand-alone chapter in this report versus folded in and integrated into other sections.  Part of the reason was that a lot of it is covered in other sections in one form or another, so it is inherently somewhat redundant, but also it wasn't originally part of the charge that President Clinton gave to us.  So we addressed this as a stand-alone chapter.  As we got into it, we decided it would be better to just weave it into everything else.

          Then we heard that Dr. Steven Strauss at the NCCAM was particularly interested in this chapter and thought it should be a separate chapter, and so we have kind of come full circle back to keeping it separate.

          The other reason for the possibility of keeping it separate was to emphasize the importance that we believe in that.  It gives us a chance to include the entire spectrum, from disease treatment to wellness, and to, in that context, delineate what is a commonality of most, if not all, CAM modalities that distinguish it from traditional Western allopathic medicine, which is allopathic medicine, in general, tends to stop at the absence of disease, as opposed to seeing it as a spectrum that goes much beyond that.

          In our conference calls, we talked about the importance of including the entire spectrum, going beyond just absence of disease to wellness, to put it in a context that goes beyond just St. John's wort versus Prozac, for example, but getting more into the philosophical issues, beyond even wellness, of healing versus curing and even death as the possibility for transformation or illness as a catalyst for transformation that goes beyond just the physical changes, even to the point of enlightenment in some spiritual traditions as one of the spectrum way beyond even wellness or curing disease.

          So, with that as kind of a global context, we can address some of the specific issues and recommendations.  Before we do that, do any of you have any comments about, in particular, whether you think this should be a separate chapter or whether you think it should be folded into other chapters?  Tom.

          MR. CHAPPELL:  I am very pleased to see it as a separate chapter.  I think self-care is a mindset of the consumer, and I think it is very different from a modality.  So, it is a way of thinking, a kind of perceiving that is important to recognize in this whole system.

          DR. ORNISH:  Just to be devil's advocate, that mindset still could be woven in.  The fact that it is a broad mindset doesn't necessarily mean it has to be a separate chapter.  Are there other reasons why you would like to see that as a separate chapter?

          MR. CHAPPELL:  You see, I don't think it gets woven in very well.  I think it needs to be separate to emphasize just how significant the shift in thinking is, that I am not giving myself over to my doctor, I am maintaining control of my wellness, and that is very different.  So, that when I am even talking with a CAM practitioner, I am still in charge as the patient.  The separate nature of the chapter and the philosophy reinforces that reality that a very large percentage of consumers has.

          DR. ORNISH:  Thank you.  Other comments?

          DR. LOW DOG:  I would just suggest that, if possible, that it go in after the definition and introduction.  I think that the wellness and the self-care is really the fundamental part of what really we are talking about.  It also is a very unifying principle, because I do think, if we are looking at Ven diagrams, I do believe that there is overlap with nutrition therapies, registered dieticians.  I think that there is overlap in there, but I think it is really the foundation, really, of where we are hoping to move in the future, which is not reliance upon any one individual outside of ourselves.

          If you think of the patient as being in the center and there being a circle around them for which there is acupuncturists and doctors and priests and preachers and surgeons, they are in the center and they are all in equidistance away, which is sort of what Tom is talking about, the foci of control, but if we are all looking at them as being equal, but each person at a different time in their life will come to it, I think that is what we are talking about.

          I don't know where it is supposed to be positioned, but, to me, it seems like it is so important and it is so fundamental that it should be the opening, before information dissemination, research, and all that kind of stuff, we should say, this is our foundation, this is the driving principles, and then we are going to move into all the rest from there.  It is just a thought.

          DR. ORNISH:  Okay.  Jim.

          DR. GORDON:  In a sense, I very much agree with Tieraona, it is one of the deepest messages that we have, the whole transformation of the health care system is predicated on a reversal of a system that does thing to and for people to one in which people act on their own behalf and then also are helpful to one another.

          I think in terms of our report, I would say it is very important to have it separate.  I am not sure exactly where in the Report, it is an interesting idea to have it right up front, but I don't know about that.  But I definitely feel it should be separate to call attention, and I feel it needs to be woven into all of the other sections, as well.  I think that it has to be separate so that people will really pay attention and they will get it that we feel it is important and they will too, and it has to be woven in, because that is so much the spirit of all the recommendations and of our principles.

          DR. ORNISH:  Thank you.  I agree, since it is our section, we would like it to be first, too.

          Effie.

          DR. CHOW:  I agree with you, it should be first.  One, it formulates, really, a basic foundation of our thinking, and this is what makes CAM different than the medical system that we are used to.  I think it should come with the overview and this chapter.

          Then the others will be based upon the premise, on how we think.  I would recommend that more should be integrated into the other chapters, the research, and all the others.

          DR. ORNISH:  Thanks.  Any dissenting opinions, since we have so many in agreement?  Since I am not there to dissent, does anyone else want to dissent?

          [Laughter.]

          DR. ORNISH:  All right.  We have a pretty clear consensus there.

          Why don't we get into the specific recommendations.  Corinne, did you want to add anything?  Do any of the other members want to add anything?

          Issue No. 1 is the utilization of CAM in schools and the community to facilitate learning, improve behavior, and optimize well-being.  Since you are all familiar with the background and challenges, why don't we move directly -- and if you are not, you can read it really quickly, while you are sitting here -- why don't we move into the recommendations, beginning with No. 64?

          DR. BRESLER:  I didn't see anywhere where consideration was made about getting to the pediatricians or health care providers for kids, too?  Was that considered by your committee?

          DR. ORNISH:  Actually, it is.  We even have a whole thing on school lunch programs and things related to that.

          DR. BRESLER:  Specifically for the health care professionals who take care of kids?

          MS. AXELROD:  That is actually Recommendation No. 71, so we will get to that.

          DR. ORNISH:  Thank you.  I knew that.  Tom.

          MR. CHAPPELL:  Thanks.  I think No. 64 is a great beginning here of what the issue is.  As I read about the idea of the working group, which normally sounds like such a constructive idea in a collaborative spirit, but the more I thought about it, the more I was saying, well, why aren't we asking for an imperative from the Secretary or an imperative from the President?

          This has such importance that I guess I am looking for a way to make more of a pronouncement, make it appear to be more important.  What is presented here is a very pragmatic idea and solution.  I am just looking for something that suggests the urgency and the total value that this has an idea.

          DR. ORNISH:  We discussed this.  Part of the issue, also, is that when talking about CAM in the schools, this for many people can be a big, red flag.  First of all, parents get very protective about what their kids are learning.  For some parents, it gets into the area of spirituality, religion, separation of church and state, cults, in some people's minds.

          So, what we tried to do was to find the right balance between not mandating or dictating something that might be an issue, but to try to integrate it this way.  We are certainly open to any ideas that anyone else has on this.

          Joe.

          DR. FINS:  Along those lines, I think Ti had said at an earlier meeting that it would be very careful not to proselytize.  The other thing here is I worry about CAM creep, where CAM becomes public health and public health is now a subset of CAM.

          So all the kinds of recommendations that you are making are really ones about health promotion, and there is a whole other part of the federal bureaucracy and scholarly areas that do not consider themselves part of CAM and see their mission as this.  I know we mentioned Healthy People 2010 elsewhere, we just have to be careful not to try to envelope the public health sector with CAM labeling.

          DR. ORNISH:  I agree with you.  If you remember, early on, when this topic was first introduced, I was arguing that our Commission should not deal with that topic at all for that very reason.

          DR. FINS:  That is why they made you chairman.

          DR. ORNISH:  Now that I am chairman, I had to find all the reasons to look why it would be useful.

          I think you can make a good case, but I do think we need to be mindful that there is a lot of overlap, not only with health promotion and disease prevention, but with several other areas, too.  But than again, much of CAM does overlap with other issues.  You are right, it is easier to just call everything that is not drugs and surgery CAM.

          DR. FINS:  Perhaps, Dean, in this particular recommendation, instead of saying, "utilize CAM principles," why don't we say, "utilize health promotion and wellness principles," which would be less alienating and less proselytizing, and I don't think would materially alter what we are recommending.

          DR. ORNISH:  We also misspelled principles here, unless they really meant CAM principals, like a school.  I think that was not the intention.

          Any comment on that before we move into others?  Jim.

          DR. GORDON:  I agree in principle, spelled either way, with Joe.  On the other hand, if you look at what is actually going on in schools, it is a horror in most schools.  I think that we have an opportunity to call attention to the mess.

          They may be saying things in health promotion, and I am sure they are, but nothing is happening, or virtually nothing is happening.  Almost all health education in schools that I have seen is, don't do this, don't do that, don't do the other thing.  The whole notion of health promotion is pretty much out the window.

          I think that there is a balance between not thinking that we invented the idea, on the one hand, and on the other hand, making an extremely strong statement.  I am not sure exactly what they are.  I would like action steps, too.  I don't know that a working group is enough, but I am not sure what else.

          I don't think we should get grandiose, on the one hand, but on the other hand, I really do feel we have to do something.  We will come back to the school lunches later on.  Actually, we don't talk about school lunches, we just talk about high-fat snacks.  The school lunches are as bad as the vending machines in many of these places.

          I think that this is a place -- we have heard it in our testimony, and we all see it every day in our communities -- this is a place where we can have a real impact.  So I just want to urge us to take that opportunity.

          DR. ORNISH:  Jim, specifically, are you recommending that we say CAM principles and practices, such as (1), (2), (3) and (4)?  What are you saying exactly?

          DR. GORDON:  I think so, yes.  We have had this discussion before and we came now down with a few things that were really important that are part of CAM but also could be seen as part of health promotion or just part of good pedagogy.  The ones I would mention are nutrition, however we want to talk about stress management, physical exercise.  Right after they cut arts programs, they cut the PE programs, and self-expression.

          If we have those things as a core, that we regard this as fundamental to the good health and to facilitating the education of children, then we are on very firm ground.  Two million kids are on Ridlin now, and the psychiatrists, god bless them, say that six million people should be.

          DR. ORNISH:  So just to be clear, then, we would say something like, "to develop guidelines on how to utilize CAM principles, such as stress management, good nutrition, exercise, social support."

          Those kinds of words are really bridge-building words, as opposed to things like "yoga," "meditation," which for many people are buzz words.  I think that would be a useful way.  Again, it kind of seizes the middle ground because then you force people to say, no, we are really kind of against exercise for kids, or, we are really against good nutrition for kids, or, we really think they should be all stressed out.

          So, I think we could add that, and I think that would make it stronger.

          Tieraona, you wanted to say something?

          DR. LOW DOG:  Actually, I had a lot of similar things to Jim.  I was wondering, the reason I also thought of putting this up front, it really brings to focus, very quickly, the impact.

          If we are looking at long-term health care and the cost of the budget, and the rising health care, and now Type II Diabetes we are seeing in children as young as 10 and 12 years of age because of obesity and diet, it really brings to bear, if we want healthy people in the future and we want to keep our costs down, that we are going to do this.

          I don't really like how to utilize CAM principles and practices.  If you want to use it, I do like health promotion, but I also think we need to be specific of what we are talking about, which, I think, is stress management, conflict resolution, physical exercise, and appropriate nutrition.  I don't think anybody would argue with those.  When I read, though, CAM principles and practices, it is a very big open.

          I will just tell you, from our own experience and our own school with our own children, even trying to get a tai chi class in, you would have thought we were going to be preaching in the schools.  We couldn't get it, actually.  We never could get it.

          So, I think if you start with stress management, you use that kind of language, conflict resolution, you use those types of words, then each school can sort of figure out what method they want to use to bring that in.

          DR. ORNISH:  What if it were something like on how to utilize CAM principles and practices, such as stress management techniques, good nutrition, exercise, social support, conflict resolution, would you be comfortable with that?

          Because the advantage of that is, particularly if this is a chapter that is early in the Report, it helps the reader who is unfamiliar with CAM to say, oh, that sounds okay.  I mean, you are not talking about aromatherapy in the schools or chiropractic in the schools, or whatever it happens to be that may be more controversial.

          Corinne wanted to clarify a point.

          MS. AXELROD:  I just wanted to mention that the rationale for the working groups is that there is a precedent in the government that they have issued guidelines which are used throughout the country, and these guidelines have been on specific topics.

          What they have done is bring together a working group, and it could be called an advisory group, or whatever, but this is the precedent that has been set for the other guidelines that have been developed, and it is actually important to bring these groups on board.

          I just wanted to explain that that is why we put in here working groups.

          DR. ORNISH:  People who haven't commented yet?  Charlotte.

          SISTER KERR:  Just a general statement, and I will just set the tone, though I go from yin and yang on this.  I am a little concerned about us trying to be so okay with the body politic.  And that is our opportunity.

          This is the core orientation, wellness, for what CAM is, what is unique to CAM.  Conventional medicine has its orientation, and we have a different orientation.  But I believe we are about transformation, and I think we need to think about the fact that we have got a system that is broken down and raggedy and spending us up the kazoo, and we might just have to be a little confrontational.

          I know both ends of that, but I want to just put that out now so we just kind of stretch a little.  We have got kids, like Jim is saying, we have got a country that needs to get its heart back, and I am just wondering if this isn't our place.  Besides our overview, and our speaking of paradigm movement and who we are uniquely, that this might be our spot.

          So, I invite me and all of us again to think, to feel, and to listen to what we want to do to breathe back into vitality to America through what we are calling healing.  Thank you.

          DR. ORNISH:  If I can just respond to that briefly.  I actually agree with you that there should be more in here about transformation, about illness or suffering as a catalyst for transformation, about the spectrum of disease treatment to wellness to transformation.  I don't view those as confrontational, though.  I don't view those as pushing people's red buttons.

          In the first study I did, we called it "Effects of Yoga and a Vegetarian Diet," and we had a hard time getting referrals, so we changed it to "A Low-Fat Diet and Stress Management," that made it okay.

          There are just certain terms that, for whatever reason, we can argue whether they should or shouldn't, but they just make it more difficult for people to hear what you are trying to say.  But I don't think that the concept of transformation is one of them, and you all know that I am pretty sensitized to red flags.  I don't see that as a red flag.  I do think it is important to get that in there more explicitly than it currently is.

          SISTER KERR:  I value and respect your experience, and also how you continue to call that forth.  I was thinking specifically of something like Tieraona just said, if we felt qigong and tai chi should begin in kindergarten.

          DR. ORNISH:  That, you would have a red flag with.

          SISTER KERR:  I understand that, but that is kind of one of my examples of we don't think that is just arbitration talk.  Maybe we need to have Big Bird doing qigong.  We need to figure out how to get Big Bird, or whoever one of these people are, doing it.

          DR. ORNISH:  Big Bird actually does Tai Chi.

          SISTER KERR:  Does he, really?  Great.

          DR. ORNISH:  Other comments?  Joe.

          DR. PIZZORNO:  I think it is important we speak our truths, and I think there are three truths here we have to speak.  One is health promotion and wellness are core to CAM philosophy.  Health and wellness promotion are core to public health, and, within conventional medicine, there is an intent to result in health by treating disease.

          So, I would like to modify the language a little bit that respects all these traditions but does not pretend that the CAM professions that have worked so hard to give this life in our society are not core to this whole concept.  So, I would change it slightly, and that would be going down to the fifth line, it would say, "Develop guidelines on how to," insert "better utilize the health promotion and wellness principles and practices typical of CAM, such as," and put the laundry list that Jim recommended, stress reduction, exercise, healthy diet, et cetera, "to improve students."

          So, clearly we are saying there is already some of this here, it is not exclusive to CAM but it is core to CAM.

          DR. ORNISH:  I also think it would be worth including the fact that allopathic medicine is based on these principles, too, going back to Sir William Osler.  It is only in more recent years that I think people have tended to lose sight of that.  Joe.

          DR. FINS:  I think we to say typical of the best of allopathic and CAM practices, because, again, I don't think we want to create a dualistic and antagonistic framework here.  It is really about integration.  It is about building alliances between the forward-thinking people in all camps.

          DR. ORNISH:  And when you think about it, it would be one of the great ironies of life if we start to polarize people in the name of CAM.  That is where I have been coming from in all of this, is to say that would be like killing for God.  To me, it is something people do, but it kind of loses sight of the main purpose of what we are trying to talk about.

          DR. PIZZORNO:  With all due respect, Joe, the reason people are going to CAM professionals is because they are not getting this from conventional medicine.  And, yes, I agree it is the best of conventional medicine, but that is not what is happening, with the exception of a relative minority of medical doctors, such as typical in this room.

          So, let's not take away from CAM its due, and I think that does.

          DR. FINS:  To be quite honest, there are people who are in CAM, under the rubric of CAM, who engage in fraud and manipulate.

          DR. ORNISH:  Okay, okay.  I am going to stop this right now.

          DR. FINS:  But the point is that CAM itself has a range of practitioners.

          DR. ORNISH:  Your points are well taken.  I think, from my particular vantage point, I want to talk about integrating the best of traditional and non-traditional practices, recognizing that there are problems in every discipline.

          DR. GORDON:  A point of procedure, if we can give back the basic principles and some consensus on the principles, then Dean and the small group can deal with the wording.  I just think we have about nine or 10 recommendations here, and we are still on No. 1, albeit that it is very important, the question is is there information that needs to go back to that group.  Clearly there are some areas of disagreement here that have been highlighted.  I just want to remind everybody that the crucial thing here is for Dean and the other members of his group to hear the perspectives of all of us.  Clearly we are not going to come up with the final wording right here.  I don't think we should try to do that.

          DR. ORNISH:  But I also think that we are not so much just stuck on the first issue, we are really talking about the broader principles that will be applied.

          MR. CHAPPELL:  I would like to support what has been said about being more focused and specific about the types of practices, but I would also like to get back to Big Bird.  I actually think this is deserving of a campaign, of a communications strategy --

          DR. ORNISH:  A CAM-paign?

          MR. CHAPPELL:  -- a communications campaign, the creation of a wellness icon, and the spokesperson that kicks this off is the Secretary of the Department of Health and Human Services.

          This needs -- and thank goodness, I am your ad guy here.  I know this stuff.  I don't know CAM, I don't know conventional medicine, but I know how to promote ideas, and this idea is big enough to be worthy of a campaign, and I would like to see that kind of language included. 

          The last suggestion I have is, at my son's school when they created a meditation room, it was like letting all CAM practices in the back door.  It was amazing.  My son was showing me around the school, and he said, this is our meditation room.  I said, oh, great.  I said, do you use this?  He said, oh, yeah, I come here every day around 5:00 and I stay for 20 or 30 minutes.  It is amazing.

          So, to be even specific about the creation of a meditation space for stress reduction is one way to just avoid this one big pill of CAM practices and be very specific and get in the door.

          DR. ORNISH:  Thank you.  We need to move on, I am being told, and I always listen to Corinne.  Effie, did you want to say something quickly?

          DR. CHOW:  I think that we can be leaning backwards in trying to think what will shock or not shock or create waves.  I think we were created to create waves, perhaps, because of the demands of the people.  I think we need to think back that we represent a broad range of people and that we use terms which are used in CAM and not water it down to what is totally accepted.  I think we can bridge it by using phrases such as and then give examples of what really is.

          I think we would be doing disservice and being not truthful nor representative, and that is why we had the thousand people that spoke before us, and spoke very strongly about various issues, and we need to speak to those issues, as well as the safe issues.

          Using words like yoga, like qigong, like spiritual healing, I think it is our opportunity to educate the people that is going to be in the position of making decisions, but still using common and understandable language, but including some of the others, otherwise we miss our whole purpose here of making significant changes and impacts on the system.

          DR. ORNISH:  I am just going to take the prerogative of responding to that briefly, because I think you have raised a really important issue, and I certainly respect your point of view.  I could make a very eloquent defense of it, as well.

          At the same time -- and this may help to explain why I find myself in the very unusual position of being the most conservative member of a group, where I am usually on the other end of the spectrum with any other group that I have been with, and that is what is the ultimate goal here.  You touched on it, Effie, when you talked about affecting change.  We can create a polemic that says everything that we want to say, and I can just tell you that it is likely to go nowhere, that it is going to offend or push so many people's buttons that we can win the battle and lose the war.

          We can just say, yeah, we said exactly what we want to say and it is completely ineffectual.  I think that we need to be mindful of the climate that we are in, the people who are going to be reading it, and how change really occurs, particularly at the governmental level, which is generally incremental.  If we tried to do too much, if we put things in people's faces, more than they are able to accept, I can just tell you from my own experiences, we will create such a backlash and such marginalization, that I am not sure that we will have anything to show for all this effort, other than a nice document.

          I am much more concerned with actually seeing things implemented and actually changing, than having the purest document, in terms of putting everything in there that we might want to say.  So, that is my particular vantage point, where I am coming from.

          DR. CHOW:  Excuse me.  I am not a revolutionist.  It is evolution, but we need to use the words that are new and to educate the people, but relate it to the words that they understand, so that you are not just throwing unknown words at them.  So, I understand where you are coming from, Dean, I also have history, and all of us have history about facing changes and have been very effective, too, as well, in respect, because, otherwise, I don't think we would be here at the Commission if we weren't mindful of exactly what you say.

          So, all I am saying is that we need to be a bit more bold, like Charlotte has been saying and Tom has been saying, and not to be stating things to be safe.  I think we have a problem there in really making our mark, because I don't think something like this is going to happen for another century, to have a Commission to take a look at the whole system and to be able to make the impact we have.  If things aren't said in our document, then it is not going to come up afterwards, because they have to read it in the document.

          I am not talking about being way out.  I am talking about utilizing both terminologies.

          DR. ORNISH:  I understand.  I don't want to belabor this, but I am not talking about being safe, I am talking about being effective, and it is different in dealing with change at the governmental level than it is in other levels that we might have been involved in.  It is not that this document doesn't talk about qigong in other places, but if we are talking about, in this particular example, what we are going to teach to kids in schools, I can just tell you, if you start putting things like meditation and qigong and other modalities of CAM, it is not a question of being safe, it is just a question of being mindful of the effect it is going to have on the readers.

          DR. GORDON:  I want to make just a brief comment.  My experience has been there are many ways to do this.  I don't think there is necessarily a contradiction.  I think one can begin by using words that are quite acceptable and then show the effectiveness of a variety of different kind of techniques and bring in many techniques.

          Michele was just sort of writing down some notes, with which I concur completely.  There is research that shows that meditation and relaxation improves learning and decreases violence -- just 30 seconds -- I have worked in schools in D.C.  We have worked in many, many schools, public, private, every imaginable kind.  We have brought in everything, including working with massage on sexually abused kids, teaching them self-massage and helping them to touch others in a loving and, as they would say, nurturing way, rather than an exploitative way.

          It is all how you word it, and if you give good examples and good research for using these approaches, then you can bring it in.  I think that is the challenge for us.

          DR. ORNISH:  And that leads us into No. 65, which is the entire intent of that.  Just as you were saying, Jim, again, I want to distinguish, we are not saying that we shouldn't be teaching meditation.  I think we should be teaching meditation in schools, but in terms of how you convey that in a document, I think, calling it stress management in No. 65, bringing in the kind of research that you are alluding to that talks about the benefits in a variety of different circumstances, it naturally flows, in the way that Tom mentioned, in terms of putting the meditation room in the school.

          But if you just say right up front, we think all schools should have a meditation room, people are going to just go, forget it, at least many people will.  I think we will be less effective.

          Again, it is a question of not being safe, it is a question of what is most skillful and most effective.  Joe.

          DR. FINS:  Along those lines, perhaps we have the direction wrong.  Perhaps we want to set up a mechanism or resource or use NCCAM or whatever entity it is, something in the Department of Education, to be a resource for those schools or school systems that choose, through the local process of the school board and local control, they want to access meditation or these modalities, so it comes from the community and reflects community values instead of it being imposed or proselytized from above.

          DR. ORNISH:  So, how would that work in practice then?  How would you word that?  I think it is an interesting idea.

          DR. FINS:  I don't have the wording quite right, but the concept is basically that we are responding to a demand or a request for assistance, an assistance program for those educational institutions that seek to begin the integrative process of bringing CAM-type modalities or wellness, depending on that semantic thing, into their school systems.

          DR. ORNISH:  But, frankly, I think that is going to read very well if say that we want to survey the communities to see what they want, to empower the communities to make those kinds of choices for what is appropriate for their local community, that kind of stuff always reads very well.

          DR. FINS:  This kind of function could be part of a CAM central set of services that would be available under that rubric.  An educational consulting service would be part of it, that would help as a resource for school systems, and of course there are different problems in first grade or twelfth grade, other kinds of challenges.  But, again, it would be based on a response to a request.

          If there are no requests, then we would know after a three-year study.  Then we would just take it out.  It wasn't meeting a real need.  But if there is an increased number of requests, then we could increase the allocation.  I think it satisfies what Charlotte is seeking to do, without getting into the proselytizing trap.

          DR. ORNISH:  Thank you.  Good suggestion.

          Other comments?

          DR. GORDON:  My sense is that this really needs to be worked on with the group, that it is a question, I think, of making some very bold statements, but statements that are, in a way, unexceptionable, of having them backed up, Joe is bringing in another issue of local initiatives and local requests, and I think all of this has to be put together.

          What is happening in this group -- this is sort of a process comment -- is we are taking on a very, very broad and very deep issue here that relates to all, as you said at the beginning, to all of the other areas that we are covering, and what we are doing is we are using our imaginations, giving us the opportunity to use our imaginations to really think about some of the broadest possible implications.

          So, I think we are giving it back to you, and now the next iteration has to do with somehow synthesizing it all.

          MS. AXELROD:  I just wanted to get some clarification from Joe Fins about your suggestion.  Are you suggesting that as an expansion of Recommendation No. 65?  That actually would fit in, I think, pretty nicely with that.

          DR. ORNISH:  Yes, he is.  Okay, good.  We move on the Recommendation No. 66, and then Issue 2.

          MS. AXELROD:  I would like to mention on Issue No. 66 that we wanted to do a little bit of change in the language to just put it in a little bit more positive light.  So, instead of saying, "be developed for schools to limit the sale and advertising," we just wanted to say something like, "to promote sale and advertising of healthy foods and products," to just put it in a positive light.  So, we will change that language.

          DR. GORDON:  I think it has got to be stronger.

          DR. ORNISH:  I would recommend doing both.  I would start it off by saying, "to encourage the sale and promotion of healthful foods and other products, and also to limit the sale and advertising of high-fat snacks, soft drinks, et cetera."

          Even Coca-Cola really recently took out their soft drinks from schools.  I think that they are really beginning to feel that the tide of public opinion is turning against that and I think we will be on effective and safe ground by putting that in there.

          MR. KERR:  I've always said until the mothers got involved in the nutrition we were going to go nowhere in this country.  Now there is a group of mothers who are into bringing the stuff out of the schools.  They would be the people that would give you some support and help if you want to carry on.

          DR. ORNISH:  I also want to just clarify, having made a glib comment, that one of the things that I think we also should include in this is that what I have found so interesting in my experiences with Medicare, for example, is how these kinds of issues really transcend the usual categorizations of right wing, left wing, Democrat, Republican, these are really human issues.  Empowering the individual, personal responsibility, opportunities for change and transformation, these are not categorized by any particular party affiliation or place on the political spectrum.  I think that in many ways it is an opportunity to bring our country together and to get past the polarization that is so often seen in other issues.  Even the fact that you had Arlen Specter and Tom Harkin coming together, I think was representative of that.

          We need to move on.

          MR. CHAPPELL:  I am just aware that we have not addressed school lunches, and I am thinking that this No. 66 is an opportunity, we could recommend examples of healthy nutrition menus.

          DR. ORNISH:  I think that is a good idea.

          MR. CHAPPELL:  The Dr. Ornish Cookbook.  I think we can empower people here without mandating.

          DR. ORNISH:  I agree.  Let's move on.

          DR. GORDON:  The only other thing that might be useful to add here is that somehow to tie in -- this is a larger subject -- to tie in the whole area of health with other subjects that kids are being taught in school.  For example, there is a very interesting program in Berkeley where they are working in the schools, they teach kids about nutrition, they teach them how to cook, they have a garden, they work in courses in Ecology.  So, it is the whole kind of integrated program.

          DR. ORNISH:  That is actually Antonia Edemis' work.

          DR. GORDON:  I'm sorry?

          DR. ORNISH:  That is Antonia Edemis' work.

          DR. GORDON:  No, it is actually not.  It is someone else's work.

          DR. ORNISH:  Well, she is doing it, too.  But I agree with you, I think that should be included.

          DR. GORDON:  I think it is that kind of approach that we can highlight and then convey as a model.

          DR. ORNISH:  Thank you.  Linnea.

          MS. LARSON:  Well, that just recalled for me John Dewey's great experiment in Chicago, at the University of Chicago, and that is exactly the model.  But there was actually a backlash against that when new immigrants came, et cetera, because it did not teach them the new things that they needed.  I think kind of a historical perspective would be important here.

          DR. ORNISH:  Moving on, and then we will circle back to other things if there is time remaining at the end.

          Issue No. 2 is utilization of CAM to help achieve the nation's health promotion and disease prevention goals.  Again, I will skip the background and challenges.

          I also wanted to mention, by the way, when I was mentioning Tom Harkin and Arlen Specter, that Dan Burton has also been a real visionary in this area here, too.

          No. 67 is "The Commission recommends that DHHS form a working group within the Healthy People Consortium that includes CAM professionals to review the 10 leading health indicators to determine the applicability of CAM to these indicators and, where appropriate, to develop strategies that encourage the use of safe and effective CAM practices in these areas."

          Joe.

          DR. FINS:  I think this is just perfect, the way it is cast within an existing framework and brings CAM into in a substantive, additive way.  I think this tone, to me, is something that should be emulated in others when we are trying to get the right balance.

          DR. ORNISH:  It was intentional to incorporate it into something that is generally accepted as being credible and valid and then by getting a halo effect of that, as well.

          Other comments or questions or concerns?  Effie.

          DR. CHOW:  I think this is good, too.  I would just like to add CAM principles and practices, add "principles" there.

          DR. ORNISH:  Okay.  Thank you.  Other comments?  Charlotte, did you have a comment?

          Moving on, No. 68, "The Commission recommends that questions on specific CAM usage be included in the national surveys that are the sources of the Healthy People 2010 data."

          Comments?  Questions?  Joe.

          DR. FINS:  Maybe the leading CAM, not everything, but just like the leading things.

          DR. ORNISH:  No, we wanted every single thing.  Okay, leading it is.  Other comments?  Questions?  Thoughts?  Feelings?

          DR. PIZZORNO:  I wanted to bring up something that was left over from the Access and Delivery, in which we were talking about demonstration projects at community health centers.  I think Michele said it was put into this section, but I looked and I didn't see it.  It seems like it would probably fit best here, under Issue No. 2.  So, I wanted to make sure we don't lose that, because I think that those community health centers demonstration projects is really important.

          DR. ORNISH:  Okay.  So, you would like to see it here, as well?

          DR. PIZZORNO:  Well, it got left out of Access and Delivery.  It was supposed to moved over here.

          DR. ORNISH:  Oh, I see.

          DR. PIZZORNO:  I think this is fine, but I don't see it.

          DR. GORDON:  Do you want to read it, so we can hear it and talk about it?  Is that okay, Dean, if he goes ahead?

          DR. ORNISH:  I don't know where it is.

          DR. GORDON:  I'm sorry?

          DR. ORNISH:  Where is it?

          DR. FINS:  We had approved it in spirit, but it didn't get into the Access and Delivery piece.

          DR. ORNISH:  Is it currently in the Access and Delivery?

          DR. GORDON:  Let's hear it, though, in this context, if there is any more discussion about it.

          DR. PIZZORNO:  This used to be No. 42, "The Commission recommends the Secretary of Health and Human Services fund model community-based initiatives through appropriations to appropriate regional offices that integrate CAM and conventional health services, especially in underserved and vulnerable communities.  The Commission supports demonstration projects and strategic planning to integrate CAM and conventional health services with emphasis on public and community health.  These groups should be funded for at least three years and be required to demonstrate collaborative efforts with local health agencies and qualified community-based providers, both CAM and conventional, and provide quality assurance and evaluation of effectiveness data from the integrated delivery system model.  The Commission strongly recommends that such demonstration projects include hospice care, that includes CAM modalities, particularly those utilizing interdisciplinary care teams, that include CP-trained chaplains and qualified CAM providers."

          DR. GORDON:  It seems to me that that ought to be focused more on wellness.  The recommendation for this use is too long.  It may work in the other section, but here there needs to be a more focused recommendation about demonstrations, I think, because wellness and health promotion get lost in that description.

          DR. ORNISH:  So, Joe, can you do the Cliff Notes version of that and e-mail it to Corinne, and then we will discuss it?

          DR. PIZZORNO:  I wonder if it should go back to Access and Delivery?  I think it should go back to Access and Delivery.

          DR. GORDON:  I see it as something that can be in both.  There is a place for it in Access and Delivery and there is a place for a slightly different version here.

          MS. CHANG:  My understanding was that those three that Joe mentioned that was missing was going to go back to our group for reconsideration, so we could figure out exactly what happened to them and where they ought to be, and that our group would reconsider those.

          DR. ORNISH:  Okay.  Let's do that.  That sounds good.  Joe, are you comfortable with that?  Okay.

          Let's move on.  Any other thoughts, feelings, questions, comments?

          MS. SCOTT:  Just for clarification, the committee, we, are going to consider adding an action recommendation here --

          DR. ORNISH:  Here where?

          MS. SCOTT:  Under Issue No. 2.

          DR. ORNISH:  Okay, which is?

          MS. SCOTT:  That would speak specifically to a demonstration project at community health centers on prevention and wellness?

          MS. AXELROD:  We will have to work on that, and it may end up being a separate recommendation.

          MS. SCOTT:  Oh, yes.

          DR. ORNISH:  Thank you.  Issue No. 3, utilization of CAM in the workplace to increase job satisfaction and productivity and to reduce costs.  The Recommendation No. 69, "The Commission recommends that a) CAM be included in all federal worksite wellness and health promotion programs; and b) federal health coverage plans offer a CAM wellness option."

          Now, this is deliberately vague, but at least it provides the general intention.  Any comments about this, either of these?

          DR. GORDON:  Did you decide to leave it vague

deliberately or is this just a function of --

          DR. ORNISH:  Well, it was originally going to be much more specific.  It is like, either you get it so specific that it is almost a book in itself, or it is so vague that it leaves people enough room to do a variety of different things.  We had a hard time coming up with specific examples that were limited.

          Corinne, do you want to address that?

          MS. AXELROD:  Well, even though it is vague, it is a really major policy recommendation, and it doesn't have the specifics in it, but if this actually were to occur, I think it would be a huge accomplishment.

          We just say include CAM in all of these programs, without defining what aspect of CAM.  This is kind of similar to our discussion on the schools that it is a local decision and that there are federal workers all over the country, in some areas they may be interested in one aspect, in other areas another aspect.  It is a consumer-driven movement, and we just want to be responsive to the people that these programs are serving.

          DR. GORDON:  My response, and then I will yield the floor to Tieraona, is, it may be too vague.  It won't give people an idea of what we are talking about, so I don't think it is going to get much play, because it will just sort of sit there and they will say, oh, well, we have jogging.  That is our CAM option.

          If it happens, people will just try to fit into it, and they are not going to be inspired by it.  I feel that this is, again, one of those opportunities we have to really inspire.

          DR. ORNISH:  Jim, what would you suggest putting in there?  Give me some specific language.

          DR. GORDON:  I can't necessarily come up with it right now, but I would think of some of the core issues, some of the same kinds of programs, some of the general categories that we talked about with school programs, but I would give some examples, and I would talk about some of the things that we have heard about in worksite wellness programs, programs that integrate relaxation therapies with physical exercise, help people focus on work, or programs that combine dietary change with exploration, you know, Chinese medicine.  It could be anything.  I think we need some examples.  We need some juice, and that would be the way we could justify it.

          I would also say that it is not just about a specific thing.  It is so easy to make a CAM option just one thing.  We need to talk about some kind of integrative approach to enhancing wellness and self-care and give some specific examples of how that might happen.

          DR. ORNISH:  Thank you.  Tieraona.

          DR. LOW DOG:  I would just second that, but I think the other thing is, not only is it kind of vague, but if I just read it, CAM be included in all federal worksite wellness and health promotion programs.

          So we are going to offer imagery, iridology, bioelectromagnetics.  I mean, you just go through the list.  It is just too vague.  If I saw it, I would just go, eh, because it is beneficial to offer a number of these services and components in the workplace, we think, but nutrition, exercise, stress management, I am not so sure it is so different than what we are offering in the school.  We are just big kids.

          DR. ORNISH:  I think there is some merit to that, both in terms of making it understandable and also making it more mainstream and assuaging any fears that might be had, that we are not talking about iridology or pyramidology in the workplace.  We are talking about things that are more generally accepted.  We can certainly change that.

          DR. LOW DOG:  The place where this dovetails with one of the earlier committees that were talking about demonstration projects to actually show does it reduce absenteeism, tying in -- was it George?

          DR. ORNISH:  Well, there are a number of worksite wellness programs that have been shown to decrease absenteeism, reduce health care costs, increase productivity.

          DR. LOW DOG:  Did we quote those?

          DR. ORNISH:  No.

          MS. AXELROD:  Yes, actually, they are in the background materials.

          DR. ORNISH:  They are in the background, but they are not in recommendations, so I think we could flesh that out a little more.

          MS. AXELROD:  And I think it is an issue that we are just going to have to look at, because a lot of the information that you have been asking for has been in the background material, and we will just have to look at how much of that we want to actually put in all the recommendations without being too redundant and wordy, but with giving it a little bit more -- sorry -- meat.

          DR. ORNISH:  All right.  Tom.

          MR. CHAPPELL:  I think this group of recommendations, No. 69, 70, and whatever, could add a search of successful models in order to publish the cost-benefit ratio or relationship here of better health, better savings to the employer.

          DR. ORNISH:  Okay.  Good idea.  Effie.

          DR. CHOW:  I think the discussion about what does it mean by CAM, and we have gone into this for various different recommendations, and I would like to refer back then, as a recommendation, that we really take a look in our first guiding principles and the chart that we said that common CAM therapies and systems of medicines, we listed a bunch of things here, maybe we could still look at that further and then add some others that are not listed there, then, as a point of reference, that when we refer to CAM that they could be selected from this listing.  This is on page 2, in the very beginning of the folder there.

          I would recommend taking a real look at that, so that we don't get into every one, so as a part of the document that they can refer back to.

          DR. ORNISH:  Thank you.  Other comments?

          SISTER KERR:  Dean, how does it fit in, if we should federalize, and most of these recommendations go to DHHS, would we still be wanting to say DHHS or would we want to say and the federal center, if there was one, just to look down the road?

          DR. ORNISH:  Well, we could say DHHS and other possible organizations.  I think it is not going to be any time soon we are going to see an office CAM or Department of CAM, I don't think we are going to see that.  I am not even sure that we would need to see that by definition if we are trying to integrate something, as opposed to creating something separate.

          Corinne, you probably know more about this than I do.

          MS. AXELROD:  Well, I think tomorrow, Don is going to discuss, Charlotte, that issue in more detail about if there is a CAM office where it would be located, and one possibility would be in DHHS.  So, even if we say DHHS, it would be up to the Secretary to then assign it, and that is a normal procedure.

          DR. ORNISH:  Are there any comments on No. 70?  We have kind of considered them together, de facto, here.  Any specific comments on No. 70 that we haven't heard already?

          DR. GORDON:  I like No. 70.  If we can be more specific about No. 69, No. 70 will fall very naturally from it.

          DR. ORNISH:  Great.  Issue No. 4, "Research on the role of CAM in promoting more optimal states of health and well-being and enhanced quality of life."  This is the section we were going to be talking about things I mentioned when I first started, about illness as a catalyst for transformation, about the difference between healing and curing, how many spiritual traditions would take enlightenment as one end of the spectrum, not just the absence of disease.  There are a lot of things that we planned to put in here that we really didn't have time to sort out beforehand.

          If you have any thoughts that you would like to have included in this section that we haven't already discussed, this would be a good time to make them known.

          Oh, I'm sorry, the research workgroup is addressing this issue.  I am in that one, too.

          DR. GORDON:  Is this being addressed in the research group, because I am not sure that I heard the discussion yesterday about optimal states of health.  I don't think I did.

          DR. ORNISH:  Well, I think you could make a case that it could be here also.  It went into the research workgroup when we were thinking of not having a separate chapter.  Now that we are going to have a separate chapter, we could easily put it back here or have it in both places, or we could have it in the research workgroup and expand more on it here.

          MS. POLLEN:  I would just like to add something to that.  It is mentioned in the background of the research material in terms of emerging areas of science and wellness, separate from disease, so that the was going to be taken and further developed.  It could be to some extent in research and also in wellness.

          DR. GORDON:  Dean, what would you like to hear from us at this point about this?

          DR. ORNISH:  Well, the background can stay in the research thing, but I think we also can expand on it more here.  I think this is where it really belongs.  I guess I am just interested to know are there specific themes, ideas, concepts, philosophies that we haven't already discussed that you want to include in here?  If you do, you could either e-mail them to us or you could say something about it now, or both.  Jim.

          DR. GORDON:  I think the one that you mentioned is the one that really breaks the new ground, the idea of transformation and the idea of transformation through illness.  Also, the other side of that is how about addressing the use of self-care, wellness, and health promotion as a means of changing consciousness.  How do people feel about that, about including that in here, because that is the other one that naturally comes up?

          DR. ORNISH:  Consciousness is one of those words that is a red flag for a lot of people, for whatever reason.  Again, I am not saying it should be or shouldn't be, but it just is.  But transformation is not, at least in my experience.  Maybe people have different ones.  Linnea.

          MS. LARSON:  I wanted to make a comment on that.  When you get into the area of consciousness studies, you get the neuroscience, you get the cognitive scientists under neuroscience, you have the semeiotics, I mean, you have a huge world that I don't think that we have the -- we don't have it.  But the general category of transformation might be quite useful.

          DR. ORNISH:  Thanks.  Mr. Chairman.

          DR. GORDON:  There is another principle that comes in here, which is not necessarily one that we have articulated as one of our 10, is that in most traditional systems of healing that I know about, the function of the particular medical care, of the health care, the highest aspect of the health care is really helping people live in harmony with themselves and with the natural and the spiritual worlds.  So, in a sense, this takes us back to our roots in traditional healing, and it takes us back to aspects of our general principles.  I think it might be a place that we would want to talk about in a way that people could understand and that would be enlightening rather than alienating for people.

          DR. ORNISH:  Thank you.  We will try to get something to you between now and the next meeting.

          Issue No. 5 is "Incorporation of CAM wellness activities in conventional health care systems to improve health outcomes and to decrease costs."  There are a number of recommendations here.  Why don't we just start with the first one, which is No. 71, "The Commission recommends that the Department of Health and Human Services, in consultation with the American Academy of Pediatrics, the American Academy of Family Physicians, the National Association of Community Health Centers, and others, including CAM professionals and consumers, develop guidelines and provide training and information on CAM and wellness to clinicians in federally-funded health programs, such as community and migrant health centers, maternal and child health programs, school health programs that provide clinical services to children and their families."

          Basically, the other recommendations just say the same thing but to other groups.  Why don't we just start with the first one, with No. 71?  Any comments or questions about that?

          DR. FINS:  General comment here, this is to develop programs and everything, but a related part of this, which may go in the regulation piece is to work with groups like -- we talked about it before -- JACO, you mentioned NCQA down here in No. 76, but also for regulation, the accreditation, the standardization of organizations of health care, hospitals, clinics, et cetera.  So, that is a slightly different take, but I think we need to put that on the list as a corollary to this.

          DR. ORNISH:  That is actually part of No. 72, as well, if you are talking about hospital association and others.

          MS. AXELROD:  Joe, just for clarification, you are suggesting that CAM programs become a part of like the JACO and other accreditation processes?

          DR. FINS:  I think we are kind of hovering around it here.  This is really to develop programs and work collaboratively in wellness.  What I am saying is that there is a role for many of these organizations to evaluate, accredit, standardize the provision of those services.

          Maybe it is a thing for Saturday, or maybe it just gets put into the Access and Delivery part, which is about regulation.  We are regulating individual practitioners, but we have nothing on regulation of organizations.  So, maybe we just bookmark that for Saturday, regulation of organizations providing CAM-related services.

          DR. ORNISH:  What do you mean by "regulation"?  I don't understand.

          DR. FINS:  Like JACO would accredit a hospital, and often as a proxy, for a state department of health to say that hospital is accredited.

          So, if the hospital is providing CAM-related services, do those organizations have the skill set or the range of expertise, et cetera, or can they regulate herbals or supplements that are in the formulary, those kinds of issues, which we haven't really addressed at all.

          MS. AXELROD:  Since this is related to wellness, that may be more appropriate for the Access section.

          DR. FINS:  I was saying that, but I just triggered that thought.

          MR. DEVRIES:  A quick comment, we might want to look through the different aspects of the Report, because it is a fair comment, Joe.  For example, on the regulatory side for health plans, the Department of Insurance and Department of Managed Health Care across the country, they are basically not just looking at benefits and how they are structured and exclusions and limitations, they are looking at quality of management systems and how you basically build your quality management, utilization management systems.  So they are very much integrated in the actual delivery of CAM.  Trust me, they regulate it and scrutinize it very, very carefully.

          DR. FINS:  I think we have to address this organizational regulation piece in a systematic way.

          DR. ORNISH:  Jim.

          DR. GORDON:  A question I have here is we say DHHS, but this is really about CAM central, in a sense, or this could be about CAM central.  So, in a sense, these are some of the functions that CAM central might serve.  DHHS is unlikely to do this itself without some kind of specific entity, it is a lot of work that we are prescribing here.

          DR. ORNISH:  Well, we are only suggesting that it would be within DHHS.  We could certainly make that more explicit, if you would like.

          DR. GORDON:  All I was thinking is that structurally this might better go eventually as part of the CAM central description or part of our mandate for CAM central, rather than under the wellness and health promotion section.

          DR. ORNISH:  Good.  Did you want to say something?

          MR. CHAPPELL:  I am thinking all of these recommendations are recommending that the department, and a department is not generative.  We need to make a recommendation.  It is either Jim's idea, or that we recommend that the Secretary or his designate -- I mean, we have got to have an entity that is generative, that is action oriented.

          DR. ORNISH:  I think that DHHS certainly implies the Secretary.  I don't think the building itself is going to do anything, if that is what you mean.

          MR. CHAPPELL:  Well, if we look at some of the other recommendations, it has been more specific to a particular agency.  It is kind of flat for me that we recommend the Department.  I might just be overly sensitive to it, but I think there are some moments when we can elevate the recommendation to suggest the Secretary.

          DR. ORNISH:  Well, which agency in particular would you like to see highlighted for these specific recommendations?

          MR. CHAPPELL:  I am talking about "The Commission recommends that the Secretary or his designate of the DHHS."  Do you understand?

          DR. ORNISH:  I understand what you are saying.  Okay.  I am not sure that I understand the distinction, but if it is important, we can certainly change that.

          MR. CHAPPELL:  It is just creating a more generative sense of the action of the recommendation.

          DR. ORNISH:  Okay.  Got it.  Thanks.

          DR. GORDON:  I'm sorry, Tom, I didn't hear the last thing you said.

          DR. ORNISH:  He said it is more generative.  In other words, it looks like there is a real person that we are asking to do something, as opposed to a faceless bureaucracy that we are asking to do something.  Is that what you are saying?

          MR. CHAPPELL:  Yes.

          DR. BERNIER:  In a nice way.

          DR. ORNISH:  He said it in a nicer way.  I am still learning how to do that.

          DR. GROFT:  Dean, actually with the Report going to the Secretary and through the Secretary, I think it would have a greater impact upon the Secretary if you designate that this activity that he look at or she look at, whoever it may be at the time, so it is a point well taken.  It would be worthwhile to point it at the Secretary.

          DR. ORNISH:  Thank you.

          MS. AXELROD:  I would just like to address Jim's comment about putting this all in CAM central.  In some cases that may be appropriate, in other cases it may not.  Just as an example, if you look at No. 74, that may be more appropriate for the Secretary to delegate to the Administration on Aging.

          Some of these others may be more appropriate to delegate to HRSA, for example.  If there is a central office, its primary function would be to coordinate and make sure these efforts happen.  In some cases they may actually be doing this, in other cases they may be delegated to an agency that actually has an infrastructure in place.

          So, I don't know that we want to tie ourselves to that at this time.

          DR. ORNISH:  I guess a larger question is, are we making too many recommendations here.  Is it better to be more selective?

          I am really not taking a point of view on this, but I am just raising it as an issue, because sometimes if you say the Secretary should do this, the Secretary should do this, he might just look at it and go, wow, that is too much, I can't do any of that.  Or, he may look at it and say, well, I could do this, but not that.  There are two schools of thought on that.

          David.

          DR. BRESLER:  I think there are some learning opportunities here that we might want to consider taking advantage of.  When you look at No. 72, for example, dealing with hospitals, which are the bastions of disease care, I don't know that they understand the difference between illness and disease and that people with a serious disease can have minimal illness and a lot of wellness.

          I think sometimes directing them to our guiding principles and saying how some of the guiding principles could fit into maternity units or emergency rooms or so forth, I am just wondering if we should go a little further in taking advantage of an educational opportunity to show how some of the principles, some of the modalities, and so forth can be integrated and some of the potential value of them for those constituencies.

          I like the idea we are doing more specific recommendations, but let's even take them out a little further and with more specificity.

          DR. ORNISH:  Thank you.  Joe.

          DR. PIZZORNO:  Actually, this is a question I wanted to ask Steve, because I have been becoming concerned about the large number of recommendations.  Is there an optimal number of recommendations, kind of a range, we should be aiming for?  I think if we have too many recommendations, then it is prioritized.

          DR. GROFT:  I think it is best to just continue the way we are going with listing out the recommendations, get the number, whatever we have right now, and as we go through the editing process, we will reduce them even more.  You will see that some really aren't as significant as others and that we might want to reduce and not do a recommendation, eliminate that as a recommendation and just put it into text.

          So, I think just go the way we are going now, and I think when ever you do your carvings, you start with something huge and you keep shaping it.  I think that is what we have to do, and I think that is what the groups will do as we continue.

          So, I am not worried, but I would think somewhere in the 40, 50 range.  Again, it is really what do we need to have an effective report, I think, to keep that in mind.  If they are solid recommendations, well thought out and well directed, it is a good recommendation.

          DR. ORNISH:  Thank you, Steve, for that recommendation.

          MS. SCOTT:  Steve, clarification.  Do you think, then, it would be helpful for those of us in our workgroups to try to attempt to say this would be our priority?

          DR. GROFT:  Yes.  I think we definitely want to do that in the future.

          MS. SCOTT:  Because I think it helps, if that is where you are going with it, and there is going to be some cut-down.  I think maybe in our groups we might want to say, well, we feel very strongly that this is, and maybe less strongly.

          DR. GROFT:  We actually started in the discussions with the workgroups to try to have you prioritize.

          MS. SCOTT:  I know.  We resisted it.

          DR. GROFT:  But you can't do it yet.  It is really premature.  I think to proceed is the way to go, and then do it later on.

          MS. SCOTT:  Okay.  Thanks.

          DR. GROFT:  Plus, we don't want to give the wrong message out that what is a priority today may not be a priority in December, as different things evolve and we become aware of new information.

          DR. ORNISH:  Thanks, Julia.

          We need to move on.  Isn't Jim going to do a summary at the end?

          MS. AXELROD:  Jim actually ceded you 15 minutes, so you have got about 12 minutes left.

          DR. ORNISH:  That gives us about two minutes per recommendation, so we should move forward.

          No. 72 is: "The Commission recommends that DHHS, in consultation with the American Hospital Association and others, including CAM professionals and consumers, identify strategies to incorporate CAM in wellness, prevention, and self-care in the nation's hospitals."

          DR. WARREN:  Shouldn't this be more in long-term care or rehabilitative care facilities, instead of hospitals?

          DR. ORNISH:  Well, we see it in both, actually, and hospitals includes both.  But if you want to say in hospitals and long-term care facilities, we can certainly add that.

          DR. WARREN:  I like that.

          DR. ORNISH:  Okay.

          SISTER KERR:  Acute care and multi-level care.

          DR. WARREN:  How much wellness can you talk to somebody in acute care?

          DR. ORNISH:  A lot, actually.

          DR. WARREN:  Can you?

          DR. ORNISH:  Yes.

          DR. WARREN:  I thought it was more like keep them alive.

          DR. ORNISH:  Not necessarily.

          SISTER KERR:  What David was saying, I thought that was a great statement.

          DR. BRESLER:  For your committee to consider the possibility of looking at this as an educational opportunity to give them specific ways in which our core principles and some of the other things we have discussed could be of great use to these various constituencies.  Just to say that we should work with them and develop strategies and plans, it is not going to go anywhere.

          DR. ORNISH:  Do you have any specific examples you would like to include?

          DR. BRESLER:  I could go on and on and on.  Pain management, for example, which is my particular area, is an extraordinary opportunity for there to be an integration of high technology and ultra-high technology with a lot of the basic core principles that we have talked about in CAM.  And there is not a hospital that shouldn't have a pain control facility, just like an emergency room or an intensive care unit and so forth.  But I am saying that the constituencies who are going to be looking at this report don't understand this.  To keep it very generic is not going to excite them or motivate them and so forth.

          I think the educational opportunity is to show them by example, for example, ways in which the things that we are talking about can enhance their activities, can be integrated into their activities, and provide better care to their constituents.

          DR. ORNISH:  So, you are really saying that you would like to see at least one or two specific examples under each one of these recommendations, as a way of orienting the thinking.

          DR. BRESLER:  Yes, and I don't know whether you want to bite off in the wellness section this distinction between disease and illness.

          DR. ORNISH:  That is going to go in the section, Issue No. 4.  Other comments?

          No. 73 -- did I miss someone?

          MS. AXELROD:  No, on No. 73.

          DR. ORNISH:  What is it?

          SISTER KERR:  Just a wording, when we get to the last sentence, including CAM professionals, et cetera, wellness prevention, self-care activities and continuing education for, and then you have the litany of physicians, pharmacists, nurse practitioners, either we should get a word, words that include everybody, for example, a sensitivity thing could be nurse practitioners, though I studied as a nurse practitioner, we ought to just say nurses.  It is not just nurse practitioners, there are many nurses who should be included.  But I wonder if we should just say health care professionals, caregivers.  Professionals excludes people, too.  What is the right word?

          DR. ORNISH:  We are being too specific, you mean?

          DR. BRESLER:  You are not even including mental health professionals on the list.

          DR. ORNISH:  That is the problem when you start getting specific, you see.  That is a dilemma that we face, once you start to make a list, then you start offending people by excluding them, whether it is a list of practitioners or a list of concepts or modalities.  So we are getting both sides of this.  Joe.

          DR. FINS:  Structurally, whether it belongs in the education section or not, where a lot of groups are mentioned by name.

          DR. ORNISH:  That was the whole point is that almost any one of these recommendations could also go in another section.  That was the whole reason why we were debating at the beginning whether it should be a separate section or not.  So, there is inherently going to be some redundancy here.  But we can certainly change nurse practitioners to nurses, I think that is a good point.  And mental health professionals.

          DR. GORDON:  The intent here is basically conventional health and mental health practitioners; is that right?

          DR. ORNISH:  Yes.

          DR. GORDON:  Which is a way to cover the whole genre.

          SISTER KERR:  Those nurses aides and people that are transporting people through the hospital, who may be the most best primary care person today because they have time to talk to people, so you know.

          DR. ORNISH:  We will just say, "including physicians, pharmacists, nurses, et cetera, et cetera."  That way, we make it clear we are not trying to limit it, we are giving examples, because then you have got the phlebotomist.  Where do you draw the line?

          MS. AXELROD:  I just want to come back to Joe Fins' comment that even though the education group is addressing CMEs that this focus here is on wellness and CMEs have such a strong focus on illness that I am afraid if we don't' make it specific as a wellness activity then that is just not going to happen.

          DR. ORNISH:  Okay.  No. 74, any comments or questions?

          Maybe in the interest of time, why don't we say Nos. 74, 75, 76, and 77, any comments or questions?  Just say which paragraph you are referring to.  Joe.

          DR. FINS:  I think on No. 74, especially given Senator Breaux's hearings recently, we need to talk about incorporating wellness, prevention, self-care, sort of the safety of this.  There has been a lot of fraud and taking advantage of that very vulnerable population.  So I think we want to appreciate that these entities not just promote but also seek to regulate.  Again there is overlap, but I think we have to be careful.

          DR. GORDON:  I have a reaction to that.  May I express my reaction, Dean?

          DR. ORNISH:  Yes, please.  I would invite you to.

          DR. GORDON:  Thank you.  My reaction is we are talking about wellness, we are not talking about somebody saying, I've got the cure for cancer, here.  I think we don't have to hedge all the time with wording about fraud.  We are basically talking about health promotion.

          DR. FINS:  I think we may want to be in touch with his office and the strong sentiments that were expressed before his committee regarding how in the pursuit of wellness a lot of unwellness and disease and abuse was occurring.  So, I think we need to be sensitive to that, whether it goes in this particular recommendation or somewhere else in the body of the Report is really immaterial, but I think there is an issue.

          DR. ORNISH:  Many people don't realize that when we ask DHHS to provide a new service of any kind, or when anyone asks them to provide a new service, it has to go to the Congressional Budget Office, where they score it, and they say, how much money is this going to cost.  They almost never score anything as saving money, it is always a cost, it is just a question of how much.

          So, even though we don't say, this is going to be paid for by DHHS, by the fact that we are recommending, we are recommending costs.  The one issue they are, particularly Medicare, are extremely sensitive to, not just John Breaux, is fraud and abuse.  A major they have with any new benefit, which in effect these would be, is the potential for fraud and abuse, even in the name of wellness, it is because of the cost issues more than anything.  So, I think it is something we need to be mindful of.

          Tieraona.

          DR. LOW DOG:  I think fraud issue was important to raise, only because lots of people are targeted with all these supplements and vitamins and things that will make you live to be 150 and that.  So, I do think it was appropriate to raise.

          But it also raises something else, and maybe it needs to go on tomorrow.  I am not sure where, but since we have been talking about wellness and self-care, and about access to vitamins or minerals, or dietary supplements that are not fraudulent but that have shown to be of benefit, such as folic acid, calcium in elder people, things that are not covered by Medicaid, Medicare, that are not often reimbursed under health care systems but that have proven health benefits.

          When we talk about access, we talk about wellness.  I am not sure where to put it, so I am just throwing it out there.  It is something that we haven't really talked about because we keep focusing on services.

          DR. GORDON:  Don't you think it goes in -- this question is for you -- the issue that you raised earlier, which is access to products?

          DR. LOW DOG:  Okay.  Yes, because it is part of wellness.

          DR. ORNISH:  When you think about it, even the prescription drug benefit that both presidential candidates were in favor of is probably never going to pass for many years.  So, it is really a very sticky wicket.

          I am not saying that we shouldn't make these recommendations, but we should also not kid ourselves about the fact that these are going to cost billions of dollars if we were to do these things.

          DR. LOW DOG:  Right.  Folic acid, I think, for women of childbearing years, I agree, and calcium for especially people at risk for osteoporosis.  I'm just throwing it out there because we are talking about including all these other things that are going to cost lots of money.  If we are going to dream, might as well dream big.

          MR. DEVRIES:  It really would qualify under reimbursement and coverage, services or products proven to be clinically safe and effective.

          DR. ORNISH:  Those are good points.

          MR. DEVRIES:  Those are good examples.

          It is a tough road.  I'm not saying it isn't a tough road, but I'm just saying that conceptually we have the right approach.

          DR. ORNISH:  We have five minutes left, so I want to make sure we have time.

          DR. GORDON:  We have five minutes.  The point I was making about fraud is more that we can't, every time we say something, talk about fraud.  I think that when it comes to public information -- and this is not just true of fraud, it is true of many of the issues we have talked about -- we have to someplace make some strong statements, but not continually make the statement, because if you continually make the statement, it is a kind of reflex that doesn't feel like it has authority.

          DR. FINS:  It was only mentioned, Jim, in the context of the aging population, which was the focus of the Senate Committee on Aging.  So, it was really in the context of that particular population.

          DR. ORNISH:  So, Joe, in the interest of time, what would you like it to say?  What would the words be?

          DR. FINS:  I think it probably goes back into the regulation section.  This is about wellness and promoting wellness, that is fine.  But if we want to talk about that particular population, I guess the point is is that the promotion of wellness sometimes is not completely innocent.

          DR. ORNISH:  I understand.  I understand the concept.  What words would you like to put in there?

          DR. FINS:  Well, I am not going to wordsmith it right now.

          DR. ORNISH:  We will take it back to our committee.

          DR. GORDON:  I think the more general issue is are some of those small additions, which don't need to be made today, necessary.  I have heard David speak, a couple of people have spoken about them, in all of these.

          So, there may be small modifiers or additions that are appropriate for each of these categories.  We talked about JCAH, and I think that people need to look at this, and if you don't come up with them now, to give them back to Dean at a later time and see how they work when they come back to us.

          DR. ORNISH:  Great.  Thank you.  We have got three minutes left to cover the remaining four issues.  Any other thoughts or comments specific to these that we haven't already discussed?

          SISTER KERR:  Excuse me, just clarification.  The last four issues, meaning these last recommendations?

          DR. ORNISH:  The last four recommendations, right.

          SISTER KERR:  And that is the end of our time period?  Because I have two new things I want to bring up.

          DR. ORNISH:  That is the end of our time period.  Well, we have got three minutes left, so we have four recommendations to talk about and then you have two new things.  It would have been easier to do if you had said something earlier.  I don't know what to do, we have only got two minutes.  So, how do you want to use the time?  New issues tomorrow?  Okay.

          I just was priding myself on trying to get this done on time.

          SISTER KERR:  They are not new, they just haven't been isolated.  We have already brought up one, and one we have talked about.

          DR. ORNISH:  Why don't you say what they are?

          SISTER KERR:  One is, I wanted to quote a Mr. Larson, who, at least four ways, has spoken to spirituality and health.  There is a handbook of health and religion that has 1,200 published studies on religion, spirituality, and mental and physical health outcomes.  He reports that 90 percent of Americans describe themselves as religious or spiritual.

          Most of conventional science -- this is important -- disregards the effect of these factors on health, and a stigma continues to exist in the research, science, and academic communities around these hypotheses, reflections on CAM.

          He has two initiatives: "Develop a centralized database on spirituality and health that contains information on grants and funding on model care and educational programs, and effective strategies for sensitivity and ethically incorporating spirituality in health care." 

          Second was: "Supporting continuing education conferences and other education materials to help make clinical and research communities better aware of research linking spiritual and religious factors to aspects of health." 

          I would like to end that statement and say the other point I wanted to make, No. 2, in light of something Tom brought up is that we should consider a communication campaign that would both educate and promote wellness from the perspective and the principles of CAM.

          DR. LOW DOG:  Charlotte, we put up spirituality and wellness as a topic for tomorrow.  Is that okay?

          SISTER KERR:  Yes.

          DR. GORDON:  I knew it sounded familiar.  This was part of the earlier wellness report.

          DR. ORNISH:  And it will be part of Issue No. 4 that we are going to be elaborating on.

          DR. GORDON:  I think there are two ways that this can be considered.  One is time-permitting tomorrow.  In any case, I think this also comes under Issue No. 4 that we have here.  So thank you.  We can deal with it there, as well.

          DR. ORNISH:  Other comments or questions?

          Thank you, Charlotte.

          I was considering Nos. 74 through 77.  I was asking for comments.

          DR. GORDON:  I would just like to add, and this is something to come back to later to think about, is in No. 77.  I think that is an appropriate place for us to get more specific, perhaps for us to give more specific recommendations.  I think it is very interesting.  It is a great recommendation.  I think that it is one of those times where we can really take an initiative and look at a little bit more closely at the kinds of things we might suggest.

          DR. ORNISH:  I also want to reiterate, Charlotte, to your point about spirituality, that spirituality and religion, the health benefits will be part of Issue No. 4, and we will be careful to make it clear that the state is not mandating specific religions or one as more healthful than another or even religion versus spirituality, but these will be discussed in that topic, because we all feel very strongly that they are important.

          DR. GORDON:  We are out of time, and then some.  Thirty seconds.

          DR. FINS:  Bereavement services, as well.

          DR. ORNISH:  Bereavement what?

          DR. FINS:  Bereavement, dealing with losses, as a component of wellness, needs to, I think, be put into this educational program.

          DR. ORNISH:  Okay.  Jim, would you like to summarize?

          DR. GORDON:  Yes.

          MS. AXELROD:  Are you referring to No. 75?

          DR. FINS:  It could nicely be incorporated into that.  Of course, the loss that we are experiencing collectively, that, I think is especially applicable.

          DR. GORDON:  I also think it might fit into the spirituality section, as well.

          Let me recap.  Actually, this was a quite wonderful discussion, because one of the things that we really did here, I feel, is to expand.  We came to a very clear sense that wellness needed to be a separate topic and that it needed to be integrated into the other sections.

          We then went on to very much look to allow ourselves to envision the impact of wellness and some of the dimensions.  So, I feel like we did some collective work here and used our imaginations.  It first came in No. 64, where there was a strong sense that we both needed to be more specific in terms of focusing on issues like stress management, food, exercise, et cetera.

          On the one hand there was a specificity that was important.  On the other hand, there was an understanding that Tom initially brought up, and I felt a certain consensus around, that this needed to be a major initiative, and in a very high profile way.  Exactly how that CAM-paign -- and I love that pun -- that campaign would be created is up for grabs.

          Tom, I hope you will work with Dean on this, because I think it is really important for you to use those skills to do that.

          On the other hand, it was very interesting that there is a kind of interplay between a federal campaign and local initiatives and what is going on locally, and that that connection seems very powerful.

          No. 65 followed.  Once No. 64 is in shape, it looked like No. 65 would follow very naturally from No. 64.

          No. 66, there was both an emphasis and on what should and what should not be in the schools, and that was a change.  We need to find exactly the right wording for it, the group does.

          Nos. 67 and 68 essentially were agreed on, as is.

          No. 69.  Again, there was an interest in having some more specificity about the kinds of programs, and with an emphasis on -- although Dean thought at first pyramidology should be included, he decided on reflection that perhaps not --

          DR. ORNISH:  Iridology, not pyramidology.

          DR. GORDON:  Iridology, okay.  So, there is a sense of we are not talking about just throwing a technique here or a technique there, what we are really talking about is a kind of integrated approach and understanding that there are going to be many different ways that this is going to be adopted in different communities and that, indeed, there may be some communities that are interested in one approach or another, and that may integrate this.  We are not being prescriptive here, but we are being descriptive of the kind of dimensions that we are looking at.

          No. 70.  My understanding was that passed pretty much as is, and that, again, we may want a little more specificity if we can give some here.  If we can't, then the recommendation would stand the way it is.

          Nos. 71 through No. 77.  My sense was that there may be specific additions to each of those, and we heard a couple, Joe's concern, particularly with issues related to fraud or the other side of it could be education to help the elderly take better care of themselves.  There are issues related to Joint Commission on Accreditation of Hospitals, that all of these could perhaps use some specific suggestions, and it was suggested that those who had some specific suggestions give them in to the committee so that they could be included in the next iteration.

          DR. ORNISH:  And also you skipped over Issue No. 4 and Charlotte's recommendation on the spirituality, which were important, will be included in that section.

          DR. GORDON:  Right.  Thank you.  And then also in Issue No. 4 there was a general sense that transformation is a quality and a characteristic and a dynamic that should be discussed, both transformation in terms of coping with illness as an opportunity for transformation and also transformation as an aspect of health promotion and wellness.

          DR. ORNISH:  Great.  Good summary.

          DR. GORDON:  Thank you very much.

          DR. ORNISH:  Thank you.  I appreciate the opportunity.

          [Applause.]

          DR. GORDON:  Just a couple of announcements.  We will have about a 20-minute break.  We will come back promptly at 4:15.

          [Pause.]

          DR. GORDON:  We will take a 15-minute break.  We will come back at 4:10.  We do have to be out at 5:00 promptly.

          Tomorrow morning there will be, after the discussion about the possibility of a creation of a CAM central office, there will be an opportunity for us to talk about our experience of the events of September 11th as a group, then we will go on to new issues.

          Let's adjourn until 10 after 4:00, and then we will come back at that time.

          [Recess.]

                Public Comments Session

          DR. GORDON:  We are now moving into the public comments section, and I see some wonderful and familiar faces.

          We are going to give three minutes per person, and then, after each panel speaks, there will be an opportunity for the commissioners to ask questions.

          Let's begin with Dannion Brinkley.

          I am very, very proud to see the human spirit being involved, and the personalities of the people is what will really make this work.

          As I watched the recommendations, knowing that I have been around for a long time, I see the potential of a real transformation.  September the 11th caused a transformation in our society, and that society cannot be healed, a lot of times, by conventional medical practitioners.  It will have to be CAM.

          You can't take a small child, who is afraid now and frightened, and drug that child into security and comfort.  It will take classroom agendas, it will take meditation, it will take calming methodologies, it will take qigong, energy medicines, to really bring a harmony and balance back into this society.

          Yesterday in the "USA Today," it was: "American Workers Rethink Their Priorities."  This is really telling us that we are on schedule, these recommendations are on schedule.  I can't help what 9/11 meant to us as a people, but what it meant to us as a world and what I saw on the days after the event that happened was what I want America to always be.

          We saw every complementary therapy and every conventional therapy at work in New York City and in Washington, D.C.  We saw it and the world saw it.

          What I would like to do is thank you guys.  Mind, body, and spirit, not spirituality -- it will evolve to that -- but mind, body, spirit, what drives this country, what makes it great is our ability to pull together, find the greatest methods and ways of doing it, and achieving it, and creating wellness.  We have the spirit of the Americas.  We have the spirit of our own religious perspectives and the spirit of our medical identities.

          I am proud, and I am really proud of you.  The interaction of the personalities shows that we not only can make this happen, but that we are making it happen.  I think that you are contributing immensely to wellness.     I want to read one thing from today's "The Hill" magazine.  "Echo of terrorist attack jangle nerves on Hill."  [Sen.] "Carper speaks of his fear for his employees and mentions reccurring nightmares, bouts of sleeplessness, and the inability to return to some kind of a normal life."

          One of the recommendations is that all federal programs incorporate a CAM modality.  You can easily mask this with drugs, but the long-term care to bring that about is the CAM perspective.  It is now in front of us.  We must seize the day.

          Once again, bereavement is a very active part in the course of where we want to go. I deal with end-of-life care, and I watch a lot of the techniques and modalities that you speak of work at the end of life.  If it works there and we focus a part of what we do in end-of-life care recommendations, we can back-engineer the whole medical profession.

          Thank you, and I'm proud of you.

          DR. GORDON:  Thank you, Dannion.  Boyd Landry.

          Now is probably the most important opportunity that I may have to give some particular insight into what it is that you have put forth in the context of the Interim Report and the draft recommendations.  It may sound a little bit stern.  I may sound a little bit upset, but please bear with me as we move through this process.  I would like to make a few general comments about the Report as a whole and then make a few specific comments about certain statements and sections in the Report.

          The Report fails to respect the rights and wishes of consumers, as it is consumers who are driving this train.  In addition, the Report fails to respect the unregulated practitioners who provide billions of dollars of service to consumers.

          Finally, the Report fails to respect the importance of the Minnesota Health Freedom Law passed last year.  The Report does not even mention it, yet the Report devotes a whole paragraph to the regulatory status of CAM practitioners.  Failing to commend or even make reference to the Minnesota Health Freedom Law is very ironic, given that the Commission devoted a significant amount of time and money to host a town hall meeting in Minnesota.

          Under Section A, "Overview of CAM," in the first paragraph, the second sentence that starts with "among" and ends with "United States," during the four town hall meetings the Commission has hosted and the seven official Commission meetings, an enormous amount of testimony has been given, which distinguishes the practical and philosophical differences between traditional, naturopathy, and naturopathic medicine.  Yet, this section of the Report treats them as though they are synonymous.

          Out of respect for the people who have successfully distinguished the two in testimony before the Commission, I would implore you to refrain from using terms that could perpetuate misinformation and cause confusion for the readers of the Report.

          In the section on page 4, "Commission's Progress To Date," the first paragraph, first sentence that starts with "the Commission" and ends with "where appropriate," it was not my observation that the majority of those who provided testimony at these hearings believed that the complete integration of CAM and conventional medicine is advisable.

          It is certainly not the opinion of the Coalition and its members.  It is our opinion that the diagnose-and-treat-disease based approach of conventional Western medicine is largely incompatible with the holistic wellness-based principles of CAM.

          A majority of practicing allopathic physicians in this country will need to undergo a complete transformation of their approach to health in order to effectively integrate CAM therapies into their practices.  Until that transformation occurs, discussion of integration is pointless and premature.

          The second sentence of that paragraph starts with "furthermore" and ends with "research."  The use of the word qualified as an adjective for CAM practitioners suggests that the government should have a role in determining who is qualified rather than letting the market forces, driven by consumers, determine which practitioners stay in business or not.

          [Interruption.]

          MR. LANDRY:  Is that time, or is that one minute?  Okay.

          This is not the role of government.  Wow, that went pretty quick.

          I will remind the Commission that my organization exists to promote and protect natural health freedoms, and it is because of our mission that I find it extremely egregious that no mention was made anywhere in the report of the Minnesota Complementary and Alternative Health Freedom Act, which both protects consumers and practitioners, and renders moot most of the arguments for licensure, certification, and registration.  Thank you.

          DR. GORDON:  Thank you.  And thank you for your attendance and your thoughtful critiques.

          Harry Swope.

          Since certification is one of your key concerns, I am here to address to you today a model which I believe illustrates how self-regulation can be applied to CAM practices.  Practitioners of homeopathy in North America have successfully addressed the issue of creating uniform standards of education, training, and certification.  Ten years ago, the community of professional homeopathic practitioners undertook this self-regulation to ensure the public could have access to safe and effective homeopathic care.

          Homeopathy is a 200-year-old healing art with a distinguished record of safety and effectiveness for both acute and chronic illnesses.  Today's practitioners are a diverse community from a wide variety of medical and non-medical backgrounds.  In 1991, the Council for Homeopathic Certification drew together recognized leaders within the homeopathic community.  Since that time, the CHC has worked with representatives of other homeopathic organizations to create standards that serve the profession and the public by creating a standard of training and competence for the professional practice of homeopathy, defining standards of homeopathic care and professional ethics, administering a rigorous examination process to certify homeopaths to this level of competence, fostering excellence in classical homeopathic training and practice, and assisting the public to choose appropriately qualified homeopaths by providing a national directory of certified practitioners at www.homeopathicdirectory.com.

          The certification process is administered by a board of directors that includes homeopaths from major health care professions and from the growing group of non-licensed professional homeopaths.

          Drawing on certification and licensing methodologies for all the major health care professions, the CHC established criteria that were appropriate to the practice of homeopathy across a wide variety of health care settings.

          Because this process was developed by prominent practitioners within the profession and because it encompasses training and ethical behavior, as well as therapeutic competency, and because it is applicable to the wide variety of health care settings that the public has come to demand, we think the CHC has created a viable model for promoting uniform standards of competence for CAM practitioners.

          Therefore we recommend that the Commission endorse the concept that each CAM profession adopt its own rigorous standards, provided that the standards ensure adequate protection of the public.

          Thank you.

          DR. GORDON:  Thank you very much.

          Len Wisneski.

          I am Len Wisneski, founding Co-chair of the Deisn Principles for the Health Care Renewal Working Group, which was formed during the Integrative Medicine Industry Research Summit in May of 2000.  Our group presented its findings to the Summit in May of 2001.

          I have been personally drawn to this work due to the absence of clearly articulated guiding principles in either my medical education or in my subsequent training.  Core principles drive the way health care operates and is experienced.  Times of change and disturbance cause to examine, clarify, and commit to renew our individual and community practices.

          Our charge is to reconnect with core, shared values based on missions, visions, and principles of diverse stakeholders.  This represents an initial effort to create a unifying view of a renewed system for health care delivery.  Many health care organizations have found that connected with principle is what allows excellent work to be engaged.

          Our group has gathered 47 sets of principles from professional associations and organizations, as well as from traditional, culturally-based health care systems.  We then developed a draft set of design principles from these 47 organizations, and I stress the word "draft."  These are not platitudes, they are practical.  These are design principles to help us shape the integration process.

          Distribution of health care resources and health care policies should follow the principles.  The principles underscore that the Commission's work is not about grafting a collection of therapies on to what we now have.  Integration is about a much broader and deeper values-driven process in American health care and in the American culture.

          Secondly, representatives of diverse stakeholder organizations at the Industry Leadership Summit agreed that we need to have the establishment of an office for complementary and alternative medicine and integrative health care inside the United States Department of Health and Human Services.

          The office would have the authority to oversee, coordinate, and direct federal, CAM, and integrative health care activities, including complementing the NIH NCCAM agenda in such areas as education, policy, health services, outcomes, cost effectiveness, and field research.

          From our perspective, if such an office is not established, we will not engage as a people and as policymakers the full breadth of meaning of this integration process which our patients, our voters, our constituents have asked for.  Without such an office, we will not embrace the principles which drive the popular movement and drove the creation of this very Commission.

          In summary, we recommend that the Commission include a set of the draft principles in its recommendations and recommend the development of consensus integrated principles by diverse CAM, conventional, and public stakeholders.  We strongly support the establishment of a federal office on complementary and alternative medicine and integrative health care on behalf of the American public.

          Guiding principles and core values are not only the heart of CAM but the heart of all health and health care practice.

          Thank you.

          DR. GORDON:  Thank you, Len.  Thank you for the work that you have done on those design principles.

          Questions from commissioners, questions or comments?  Tom.

          MR. CHAPPELL:  Is it Harry Swope?

          DR. SWOPE:  It is Harry Swope, yes.

          MR. CHAPPELL:  Thank you.  It was very interesting to hear your example.  I wonder, have you learned from the failings of other professional groups why self-regulation hasn't worked more effectively for them?

          DR. SWOPE:  That is a difficult question to answer.  I think my personal ethic dictated that I go to naturopathic medical school, four years, get a degree, get a license in order to practice, but I still honor the fact that people who dedicate themselves in an appropriate way to the public safety aspects of practice can do, in particular, homeopathy.

          I am not so confident that I would like to have non-licensed people doing naturopathic care, but homeopathy, because of its inherent safety, because nobody, to my knowledge, has ever been harmed by a homeopathic remedy properly administered.

          The key is more, in my mind, making sure that our practitioners understand the public safety aspects, the physiology, the anatomy, the pathology so that not that they can diagnose, not that they can treat as a medical doctor would, but that they are aware of what the issues are, that they aren't silly about it, that they aren't cavalier about it.

          This is not a religion.  This is health care.  This is a public service.  It carries a public duty with it.  I would think that the people who are not willing to step up to honoring the necessity to protect the public by doing some work, by doing some study, by stepping up the standard, create problems for themselves.

          That is why I created, along with some of the other leaders in homeopathy, the Council for Homeopathic Certification, so that among the people out there practicing homeopathy, if I want to refer my mother, as I have, to a homeopath in Maryland, and I am not in Maryland, I have some way of knowing who is adhering to the standard, because they have stepped up to what we have asked them to do to be certified by our Council.

          MR. CHAPPELL:  Thank you.

          DR. GORDON:  Thank you.  Other questions or comments?

          I wanted to say a couple of things.  One is, I wanted to especially thank the three of you whom I have known for some time now and seen before.  Especially, I want to thank Dannion for your support and your thoughts and your spirit, and for being with us all the way.

          I wanted to say to Boyd Landry that I appreciate your analysis and your persistence.  They are very important.  And the Minnesota model is important.  I was just checking through the Report, and I realized it is not in the Interim Report.  It has very much been a part of our thinking and a part of our reflection.  Certainly, we will be dealing with it in the Final Report.

          I think that we are sensitive -- and we appreciate your thoughts about it -- but we are sensitive to some of the issues of people who are community-based or traditional practitioners.  I hope that our discussion reflects it.  As you read over what goes up on the site following this meeting, I would appreciate any further input that you have.  I am sure that there are some differences of opinion between various ones of us and you, but I also think that your voice is crucial to helping us understand some of the issues.  So I really wanted to thank you for that.

          And, Len, I wanted to say that I would like to ask you and others from the group that you are working with to take a look at the principles that we have articulated, which are very much going to guide us.  I think that what you will see, what I saw when I was out at your meeting in Arizona, is this tremendous amount of congruence between our principles and many of the principles you have articulated.

          The other thing I want to say is that for all of you -- and I appreciate your putting the emphasis on the importance of a creation of an office, we are going to be talking about that tomorrow morning.  As you know, our recommendations are only, even though we will have spent close to two years in listening to a thousand people in person and a couple thousand people, at least, who have communicated with us, our recommendations will only have force if the various communities that are interested mobilize themselves.  Clearly, you will be able to see what we say in relationship to having a central office, and we would appreciate any input about that central office.  And, remember, if it is going to happen, it is going to depend on very strong public support, support of practitioners and of the general public to make it happen.

          I just wanted to share those thoughts with you.

          DR. WISNESKI:  Jim, I appreciate what you are saying, and I am sure our group would be very pleased to look at the principles that were articulated by the Commission; however, we are not promulgating a set of principles, we are promulgating a process by which all stakeholders can articulate principles which may end up looking somewhat different from what you see in front of you today.  That process, when honed and embodied, will help renew, rejuvenate, and redesign the health care delivery system of our country.

          DR. GORDON:  Great.  Thank you.  Other questions or comments?  Dannion.

          MR. BRINKLEY:  I know I get more excited than most of you guys, because you sit and deal with it, but right now the place that I'm focusing in is veterans, and I look at the end-of-life care for veterans.  I watch a lot of the therapies you talk about work in veterans at the end of their lives.

          We are now looking at a country preparing to go to war or participating in war, every major person that is of any position of power from Colin Powell to a son protecting his father, a World War II veteran, which my father is a disabled World War II veteran who uses this type of stuff because I bring it home from you to him.

          Now, when you look at 24,800,000 veterans, you look at the loss of 45,420 per month, and it is a closed system.  If we take time to focus on the veteran who is about to go and serve, and look back at those who did serve, you have the opportunity to create the greatest model for conventional and complementary integration into a closed system that can be researched and looked at.

          I know the 24.8 million people whose sons are now going to war, whose fathers went to war, and who -- I am a veteran myself -- are going to look strongly at moving this forward and getting it established as an office of what Len was talking about, and you are the people who can make it happen.

          I look at this, we are losing and preparing, and we are all in the middle with our hopes and dreams.  I just wanted to make sure that you guys take time to look at the veteran, look at the VA system, and, as you look, instead of generally out in the whole world, look at it in that context and that criteria, because it is all there.

          It is a cross-section of all we are, and it is a place where the opportunity avails itself to walk in and create the system.  Then move it back out into the general public, because they have already paid for the service.  We are trying to bring the best quality of care to them that they have paid for already.

          DR. GORDON:  Dannion, thank you for the reminder.  We heard testimony from the VA, and I think a lot of us share your feelings.  Any concrete suggestions, if you want to write out -- because part of what I think you heard today is, in some of our recommendations we are trying to make them more concrete -- any thoughts, specific thoughts, you have about the VA, we would really appreciate getting, because I agree with you, that is one of the areas where we can really, perhaps, make a difference.

          MR. BRINKLEY:  It is going to make the political side pay attention.  It is going to make politics pay attention that we are not a bunch of people just sitting here trying to do something whimsical.  It is going to show that if a World War II veteran who spent time in a German prison camp, and I can use aromatherapy and color therapy on him -- and it may be a little anecdotal -- but he leaves this world in peace and in comfort.

          There is a viable position that we can take in the political arena that makes this stuff move forward, and that moves some academia and medicine into the political force, and then out into the public, because supposedly we are going to take care of those who stand up and defend us.

          Thank you.

          DR. GORDON:  Thank you.  Thank you all.

          [Applause.]

          MS. CHANG:  Thank you.  If the last three would come up now.  Daniel Benor, David Molony, and Susan Delaney.  Thank you.

          DR. GORDON:  Welcome, Dan Benor.

          I am here to share with you a little bit about spiritual healing, as in Reiki, therapeutic touch, prayer.  Not knowing most of you, I would just like a show of hands, how many are familiar with Reiki or therapeutic touch or this sort of treatment.

          Good.  So I am not talking from point zero.

          I have, as a physician and psychiatrist, been very skeptical about this when I first started looking at it.  It has been a process of about 20 years of exploring healing, to the point where I am absolutely convinced that it does work.

          I have managed to get my publisher to agree to give you copies -- if you haven't received your copy, they are out in the lobby -- of "Review of 191 Controlled Studies of Healing," showing that it is a potent intervention.  It can have effects in humans, animals, plants, bacteria, yeasts, enzymes.  So that there is really no question that it is an effective, potent intervention.

          Healing, as in mental intent, as in prayer, works.  Our prayers do have effects in the real world, not just hopeful effects, wishful effects, placebo effects, but actual effects on physical illness, not just in humans, but in animals and plants.  This is not a placebo.  This really does work.

          I have been blessed to be able to work with a group of people, the Council for Healing.  We are bringing together the collected awareness, knowledge, experience of people who have studied therapeutic touch, healing touch, qigong, Reiki, other forms of healing, so that we can work together and learn together how healing can be most effective as an integrative component in our health care.

          We are not interested in promoting this as an alternative, we feel that that is a very divisive term, although it is the most term that people have used.  We would like this to be an integrative component of health care.  We would like to see this introduced more and more in nursing schools and medical schools, and we are hoping that the work of this Commission can make that more and more possible.

          Thank you for the opportunity of speaking here.  I have given a handout that includes the list of the people participating and contact information and some of our ideas on ways forward in research.  We know that healing does work, our next question is how does it work.  Thank you.

          DR. GORDON:  Thank you.  And thank you, Dan, for all your wonderful work.  Susan Delaney.

          I am here at the request of Dr. Gordon, who received the letter which you have in your packets regarding different types of licensure.  The challenge is before this Commission, looking at some of these issues of public safety, access, and also freedom of choice.  We believe that you can use licensing as a mechanism to address some of these issues.  So how you can maintain freedom of choice, access, with accountability?

          So, professions that are trained to diagnose, to treat, and to prescribe, licensure really is the only answer, whereas, for herbalists or root doctors, maybe certification or registration might be more appropriate.  Let's make these two distinctions, there is the title act and the practice act, both are licensing acts.

          So, a title act sets up educational standards and defines the therapeutic modalities that a practitioner may use.  For example, a naturopath would be an example, so there would be four-year degrees, licensure from accredited schools, and passing of a national exam.

          Then the therapeutic modalities may be nutrition, herbs, homeopathy, hydrotherapy, but this title act does not restrict the practice of these modalities by anyone else, by a chiropractor, by herbalists, or by homeopaths.  So the title act gets you to call yourself an ND, or naturopathic physician, but it does not restrict these.

          However, a practice act, like the Medical Practice Act or Chiropractic Practice Act, clearly does those same two things, yet it defines the scope of who can practice medicine or who can practice chiropractic.

          Some of the disadvantages of that would be like the chiropractors in North Carolina don't get along so well with the physical therapists, so there are some turf battles and competition and fighting there, whereas, in North Carolina, the acupuncturists have a title act.  So acupuncture is practiced by chiropractors; it is practiced by MDs, but you cannot call yourself an acupuncturist unless you have met these certain standards.

          So, a title act would do five things, which you have listed there.  It would support competency, set educational standards, and protect the public.  This is important for public confidence, it really is.  It would also provide access to CAM providers, like naturopaths.  In Washington State, where there is a license, there are over 700 naturopaths.

          In my state, where it is unlicensed, it is a misdemeanor.  We have a policy, don't ask, don't tell, and there are only 12 of us there.  So, the access to naturopathic medical physicians is being restricted.  It clarifies the expectation in the marketplace.

          So, the state where the eight-year-old girl died at the hands of an unlicensed naturopath because he was advertising in the Yellow Pages as a doctor of naturopathy, the mother did not understand that he had a degree that was from a mail-order school.

          DR. GORDON:  Susan.

          DR. DELANEY:  Do I have to stop?  Okay.

          So, we are recommending licensing.

          DR. GORDON:  Do you want to conclude with a sentence or two?

          DR. DELANEY:  Well, we would like to recommend licensure for naturopathic physicians, using a title act or a practice act, but preferably the title act.  It allows for more flexibility.  Thank you.

          DR. GORDON:  Thank you.  Thanks for coming back and talking with us again.  At least up here, we don't have copies of your testimony.

          DR. DELANEY:  There was a letter that was sent to you.  It should be in your notebooks.

          DR. GORDON:  We don't have it.

          DR. DELANEY:  Okay.

          DR. GORDON:  So if you could send that again, we would appreciate it.

          DR. DELANEY:  Okay.

          DR. GORDON:  Questions from commissioners, questions or comments.  Tom.

          MR. CHAPPELL:  Dr. Benor, thank you very much.  I am just curious to know why you want to know how it works.

          DR. BENOR:  After spending 20 years researching this -- this book in front of you is a baby of 20 years gestation -- I have got a lot of curiosity because of the different ideas and theories behind what different practitioners say that they do.

          I don't know that it is going to make a difference to the person receiving it, but sometimes it does make a difference in how it is delivered.  For instance, people believe that prayer is different from mental intent.  I don't know that we can ever prove it, but I think the investigation of this would bring us closer to working together with people who know how to pray pretty well, pretty effectively.

          And so, the process of exploring it, I think, would help to bridge some of the divides that our society has brought into being.

          The average doctor feels that prayer is the province of the church, but I think it should be the province of every health care provider, to some degree, to whatever degree they are comfortable.

          MR. CHAPPELL:  Thank you, that does sort of provide motivation for me, as well.  Have your studies included alcoholism?

          DR. BENOR:  There is one study by Scott Walker of alcoholism that was funded by the NIH.  It showed that there was a greater percent of people persisting in treatment, although the effects of the treatment were no better with those who were prayed for by the people who were designated to pray.

          DR. GORDON:  Dan, you are referring to a study where people are being prayed for, not a study where they are praying?

          DR. BENOR:  That is correct, Jim.

          DR. GORDON:  So it is an intercessory prayer study?

          DR. BENOR:  Yes.

          MR. CHAPPELL:  I see.  Thank you.

          DR. GORDON:  Joe.

          DR. FINS:  Dr. Benor, I just want to ask you, we have had a lot of discussion on methodology, and, how do you know if something actually works or not, and a paper that we briefly discussed yesterday was by Andrew Vickers' "Do Certain Countries Produce Only Positive Results: A Systematic Review of Controlled Studies."

          In your own work, how have you addressed the biases or the accuracies of the studies that you cite?  What are the criteria that you use for inclusion in your work?

          DR. BENOR:  I looked for randomized, double-blind, controlled studies, and in the book in front of you, I have ranked them according to whether they adhere to the minimum of scientific standard.  The book you have is the first of two.  The second will be a professional supplement, which includes many more details of the studies and the statistical data, for those who are interested in those details.

          Your question is a proper one.  The book contains a little sheet there, listing the studies that are of high standard, and you can see that there are a good 30 studies there that I classify as of high standards, and they are not just in humans, they are in animals and plants, as well.

          DR. FINS:  Just a brief follow-up.  Do you have any kind of concrete recommendation for the research infrastructure and how to bring increased methodologic rigor into NCCAM and training programs, any ideas along those lines that you could share with us?

          DR. BENOR:  I would strongly encourage people who are setting out on doing studies to seek expert consultation.  I sometimes weep over the efforts that have been put out to do major studies where there are serious flaws that could have been avoided with proper consultation.

          DR. GORDON:  Charlotte.

          SISTER KERR:  You know that expression in the lay press when you want to read a book, about I can't until the end?  So I want to ask you a question before I read your book.

          For example, I know you studied Olga Worrell and Meitk.  I don't know if you looked at other conventional doctors or nurses who seem to have unusual results.  Did you find that there were five major factors that facilitated this particular blessing on people?

          DR. BENOR:  I love your question, and every time I think I have the answer to it, someone comes along to show me that I am wrong.  But on the average, compassion and love and caring, and a belief in something transcendent that can bring in a change that is beyond what we would expect within conventional medicine, can make it possible.

          We don't have all the answers in conventional medicine, much as we would like to believe that we do.  I have seen, myself, several healings that were medically impossible.  I have heard of many others where people were transformed when there was no hope within conventional medicine.  But something happened.  We don't know how that happens yet.

          That is part of my interest in further research.  How can it be that someone with a cancer one day can be without cancer in a few weeks or months, sometimes instantaneously?  That begs us to do further research.

          DR. GORDON:  Excuse me.  We only have five minutes.  I wish we could go on longer, but the delayed David Molony has now arrived.

          Welcome.

          We want to hear his testimony.  I don't know if there will be any time left to talk with Dan.  So, I'm sorry to cut short the discussion.

          David.

          Thank you for allowing me to speak to the members here today.  I am Dan Molony.  I am a professional acupuncturist and executive director of the American Association of Oriental Medicine, founded in 1981, and the oldest and largest national organization of acupuncture and oriental medicine professionals.

          We were instrumental in creating the National Certification and Accreditation Commissions for acupuncture and oriental medicine, and for passing licensing statutes in many of the 40-plus states that are licensed.

          Providers of primary care services include, in China, nearly three-quarters of a million doctors of conventional medicine, and over half a million doctors of traditional Chinese medicine.  These two different systems of medicine coexist harmoniously because the Chinese citizens have equal access and a basic understanding of both systems.

          Their conventional medical doctors were raised in a country familiar with its own tradition, while their doctors of traditional medicine have training that encompasses an evolving system of medicine that is rounded out with a year or more of conventional diagnostic and therapeutic principles and procedures.

          Both professions are thus reasonably well prepared to help patients make informed decisions about their health care options.  We support similar direct access to oriental medicine professionals in this country, who are well trained and licensed as primary health care practitioners providing independent services to a wide spectrum of patients.

          We also support access to oriental body work therapists in their own right, and whose standards of practice leave little potential for confusion of their services as a substitute for comprehensive medical diagnosis and treatment.

          The MM is working to bring professionals to the table to begin a dialogue to create a basic, entry-level training standard of oriental medicine modalities across the board within all fields of medicine in this country.

          Nobody is sure how this will look when it is finished, but any neutral party can be sure that those with financial interests in training any particular group's practitioners should not be a participant in the discussion.

          Discussion and development of these criteria must become disentangled from the politics of the educational processes of our disparate fields and evaluated by those with lengthy, clinical expertise from those fields, so as to provide input from the patient's perspective, since it is the patient who is at risk.

          This sort of seed of change is something the that White House Commission has been commissioned to do and will require a small but vigorous stimulus to germinate the beginning of a major change in the field of oriental medicine which might provide a template for further change within CAM with all its Shiva-style arms, many working against each other, to the patient's detriment.

          The MM would be proud to work with the Commission to help in whatever way we can in order to enhance public safety and professional efficacy on the patient's behalf.

          I would like to thank the Commission for your efforts to improve health care in America.

          DR. GORDON:  Thank you very much, David.

          We probably have time for one more question for any of the three panelists.  Does anyone have a question?

          [No response.]

          DR. GORDON:  Okay.  I want to thank you for returning and for speaking with us, and for making it here.  We really have appreciated this input today, and your ongoing input to us.

          Dan, I think if you have any specific suggestions -- I think this is what Joe was asking for in terms of research methodology -- we would really appreciate it, around issues of spirituality and spiritual healing, because, and I don't know if you were here for that section today, we are really in the early stages of formulating our approach to it.

          Even though we have thought about it a lot, we are still kind of coming together on it right now.  So, any thoughts that you want to send us, if you want to send us criteria or any thoughts at all, based on your years of study, we would appreciate that.

          Incidentally, I don't know, Susan Delaney, if you heard our discussions, we are grappling with licensure and have very much appreciated input about title licensure.  It has been an important educational process for us.

          We are going to adjourn now.  Tomorrow, I want to remind everybody, we are meeting at the Bethesda Marriott Suites, 6711 Democracy Boulevard.  There are maps at the desk.  We are starting at 8:00 tomorrow.  We will begin at 8:00.  The first session will be on Coordinating and Centralizing Federal CAM with Don Warren, with Joe Kaczmarczyk, leading.

          We will take a break, then we will spend some time talking about our responses to the events of September 11th.  We will devote some time to new issues, talk about preparation of the Final Report, and we will adjourn by 12:30.  Beth Clay will also be speaking with us early in the morning, right after the introduction.

          So thank you all for this long and full day, and for all your attention and contributions.  See you tomorrow morning.

          [Applause.]

          [Whereupon, at 4:53 p.m., the meeting was recessed to reconvene at 8:30 a.m., Saturday, October 5, 2001.]

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